Appendix 1: Case Definitions and Disease-Specific Information - Infectious Disease Protocol
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Ministry of Health Ontario Public Health Standards: Requirements for Programs, Services and Accountability Infectious Disease Protocol Appendix 1: Case Definitions and Disease- Specific Information Disease: Gonorrhea Effective: May 2022
Gonorrhea
☒ Communicable
☒ Virulent
Health Protection and Promotion Act (HPPA)
Ontario Regulation (O. Reg.) 135/18 (Designation of Diseases)
Provincial Reporting Requirements
☒ Confirmed case
☒ Probable case
As per Requirement #3 of the “Reporting of Infectious Diseases” section of the
Infectious Diseases Protocol, 2018 (or as current), the minimum data elements to be
reported for each case are specified in the following:
• O. Reg. 569 (Reports) under the HPPA;6
• The iPHIS User Guides published by Public Health Ontario (PHO); and
• Bulletins and directives issued by PHO.
Type of Surveillance
Case-by-case
Case Definition
Confirmed Case
Neisseria gonorrhoeae (N. gonorrhoeae) detected in an appropriate clinical specimen
(e.g., urogenital, rectal or pharyngeal swab)
Probable Case
Clinically compatible signs and symptoms in a person with an epidemiologic link to
a laboratory-confirmed case
2|PageOutbreak Case Definition
The outbreak case definition varies with the outbreak under investigation. Please
refer to the Infectious Diseases Protocol, 2018 (or as current) for guidance in
developing an outbreak case definition as needed.
The outbreak case definitions are established to reflect the disease and
circumstances of the outbreak under investigation. The outbreak case definitions
should be developed for each individual outbreak based on its characteristics,
reviewed during the course of the outbreak, and modified if necessary, to ensure
that the majority of cases are captured by the definition. The case definitions should
be created in consideration of the outbreak definitions.
Outbreak cases may be classified by levels of probability (i.e., confirmed and/or
probable).
Clinical Information
Clinical Evidence
A clinical consultation is necessary in probable cases for verification of signs and
symptoms. Consideration should also be given to laboratory screening of
asymptomatic persons who have risk factors for N. gonorrhoeae.
Symptomatic females may experience an unusual vaginal discharge or bleeding,
painful urination, lower abdominal pain and pain and/or bleeding during vaginal
intercourse.
Males may experience urethral discharge, itching and painful urination.
Pharyngeal and rectal infections are mostly asymptomatic, but rectal gonorrhoea
can be associated with rectal pain and discharge.
Clinical Presentation
Many cases are asymptomatic.2 If symptoms do occur, they usually appear two to
seven days after infection.3
In males the most common presenting symptom is a painful purulent urethral
3|Pagedischarge; dysuria and frequency as well as redness, itching and swelling of
urethra.1,2
Females present with initial urethritis or cervicitis, frequently mild which can go
unnoticed; abnormal vaginal discharge and post-coital bleeding may occur and
then the infection can progress to pelvic inflammatory disease.1,2
Pharyngeal and rectal infections can occur among those engaging in oral and anal
sex respectively.1 Most rectal and pharyngeal gonococcal infections are
asymptomatic, however, if symptoms are present in rectal infections individuals
often display rectal discharge and pain.1,2,4
Can present as conjunctivitis (Ophthalmia neonatorum) in infants.1 For more
information regarding gonococcal conjunctivitis in infants, please refer to the
Appendix for Ophthalmia neonatorum.
Laboratory Evidence
Laboratory Confirmation
Any of the following will constitute a confirmed case of Gonorrhea:
• Positive N. gonorrhoeae culture
• Positive for N. gonorrhoeae nucleic acid amplification test (NAAT)
• Positive Gram stain negative intracellular diplococci on urethral smear (in
males only)
Approved/Validated Tests
• Standard culture for N. gonorrhoeae
• NAAT for N. gonorrhoeae
• Gram-negative diplococci on a smear of urethral discharge (male only)
Indications and Limitations
• Drug sensitivity testing can only be performed on positive cultures and is not
available for NAAT specimens.
4|Page• Refer to Ontario Gonorrhea Testing and Treatment Guide, 2nd Edition (2018, or
as current) for testing recommendations.
For further information about human diagnostic testing, contact the Public Health
Ontario Laboratories.
Case Management
In addition to the requirements set out in the Requirement #2 of the “Management
of Infectious Diseases – Sporadic Cases” and “Investigation and Management of
Infectious Diseases Outbreaks” sections of the Infectious Diseases Protocol, 2018 (or
as current), the board of health shall investigate cases to determine the source of
infection. Refer to Provincial Reporting Requirements above for relevant data to be
collected during case investigation.
Boards of health can choose to consult the PIDAC Sexually Transmitted Infections
Case Management and Contact Tracing Best Practice Recommendations (2009, or
as current) for best practice guidance on case management.8
Treatment as per attending health care provider; refer to the Ontario Gonorrhea
Testing and Treatment Guide, 2nd Edition (2018, or as current) for treatment and
follow up recommendations.4
Refer to Sexual Health and Sexually Transmitted/Blood-Borne Infections Prevention
and Control Protocol, 2018 (or as current), Ontario Gonorrhea Testing and Treatment
Guide, 2nd Edition (2018, or as current);7,4
Boards of health can choose to consult PIDAC Sexually Transmitted Infections Case
Management and Contact Tracing Best Practice Recommendations (2009, or as
current) for additional guidance on contact management and follow-up.8
For further information regarding multi-drug resistant gonorrhea please refer to the
Ontario Gonorrhea Testing and Treatment Guide, 2nd Edition (2018, or as current).4
For information on alternative treatment guidance options in individuals with
contraindications to first-line treatment (i.e., cephalosporins given in combination
with azithromycin or doxycycline) refer to Public Health Agency of Canada’s
Treatment of N. gonorrhoeae in response to the discontinuation of spectinomycin:
5|PageAlternative treatment guidance statement (2017, or as current).5
Contact Management
For contact management of cases, refer to the Sexual Health and Sexually
Transmitted/Blood-Borne Infections Prevention and Control Protocol, 2018 (or as
current), Guidelines for Testing and Treatment of Gonorrhea in Ontario (2013, or as
current), and PIDAC Sexually Transmitted Infections Case Management and Contact
Tracing Best Practice Recommendations (2009, or as current).7,4,8
Outbreak Management
Please see the Infectious Diseases Protocol, 2018 (or as current) for the public health
management of outbreaks or clusters in order to identify the source of illness,
manage the outbreak and limit secondary spread.
Prevention and Control Measures
Personal Prevention Measures
Preventative measures include counselling and risk education strategies about safer
sex practices including use of condoms and early detection of infection by
screening those at risk.2
Refer to Sexual Health and Sexually Transmitted/Blood-Borne Infections Prevention
and Control Protocol, 2018 (or as current), and the Canadian Guidelines on Sexually
Transmitted Infections (2018, or as current).2,7
For screening and testing recommendations please refer to the Ontario Gonorrhea
Testing and Treatment Guide, 2nd Edition (2018, or as current).4
Infection Prevention and Control Strategies
Refer to PHO’s website to search for the most up-to-date information on Infection
Prevention and Control (IPAC).
6|PageDisease Characteristics
Aetiologic Agent - Causative agent is the Neisseria gonorrhoeae (N. gonorrhoeae), a
gram-negative diplococcus, commonly known as gonococcus.1
Modes of Transmission - Sexual contact via oral, vaginal, cervical, urethral or anal
routes; in children, consider the possibility of sexual abuse; newborns: during
delivery from infected mother.1,2,4
Risk factors for transmission include:
• Sexually active youth under 25 years of age;
• Men who have sex with men;
• Those who have had contact with a person with proven gonorrhea infection
or a compatible syndrome;
• Sex workers and their sexual partners;
• Street-involved youth; and
• Individuals with a history of gonorrhea or other STI infection.4
Incubation Period – In individuals who display symptoms, the incubation period is
usually 1-14 days.1
Period of Communicability - May extend for months if untreated; effective
treatment usually ends communicability within hours.1
Reservoir - Humans.1
Host Susceptibility and Resistance - General susceptibility.
When considering re-infection, primary treatment failure and inadequate treatment
please consider the following factors:
• Appropriate treatment provided considering Ontario Gonorrhea Testing and
Treatment Guide, 2nd Edition (2018, or as current);4
• Treatment adherence;
• Necessary follow up completed (i.e., test of cure undertaken if
7|Pagerecommended);
• Avoidance of sexual exposure during treatment period and 7 days post
treatment.
For surveillance purposes, if the above factors are met health units may consider 28
days for re-infection.
Please refer to PHO's Reportable Disease Trends in Ontario reporting tool for the
most up-to-date information on infectious disease trends in Ontario.
For additional national and international epidemiological information, please refer to
the Public Health Agency of Canada and the World Health Organization.
Comments
• Conjunctivitis in infants less than or equal to 28 days caused by N.
gonorrhoeae should be reported as ophthalmia neonatorum.
• Gonorrhea infections are asymptomatic in up to 50% of females and 10% of
males.
• For screening and testing recommendations please refer to the Ontario
Gonorrhea Testing and Treatment Guide, 2nd Edition (2018, or as current).
• When considering re-infection, primary treatment failure and inadequate
treatment please consider the following factors:
o Appropriate treatment provided considering Ontario Gonorrhea Testing
and Treatment Guide, 2nd Edition (2018, or as current);
o Treatment adherence;
o Necessary follow up completed (i.e., test of cure undertaken if
recommended); and
o Avoidance of sexual exposure during treatment period and 7 days post
treatment.
• For surveillance purposes, if the above factors are met health units may
consider 28 days for re-infection.
8|PageReferences
1. Heymann DL, editor. Control of Communicable Diseases Manual. 20 ed.
Washington, D.C: American Public Health Association; 2015.
2. Public Health Agency of Canada. Canadian Guidelines on Sexually
Transmitted Infections [Internet]. Ottawa, ON: Her Majesty the Queen in Right
of Canada; 2018 [cited May 15, 2018]. Available from:
https://www.canada.ca/en/public-health/services/infectious-
diseases/sexual-health-sexually-transmitted-infections/canadian-
guidelines/sexually-transmitted-infections.html
3. Government of Canada. Gonorrhea [Internet]. Ottawa, ON: Her Majesty the
Queen in Right of Canada; 2017 [updated July 7, 2017; cited February 20,
2018]. Available from: https://www.canada.ca/en/public-
health/services/diseases/gonorrhea.html
4. Ontario Agency for Health Protection and Promotion (Public Health Ontario).
Ontario Gonorrhea Testing and Treatment Guide, 2nd Edition. Toronto, ON:
Queen's Printer for Ontario; 2018. Available from:
https://www.publichealthontario.ca/-/media/documents/G/2018/guide-
gonorrhea-testing-treatment.pdf
5. Public Health Agency of Canada. Treatment of N. Gonorrhoeae in Response
to the Discontinuation of Spectinomycin: Alternative Treatment Guidance
Statement. Ottawa, ON: Her Majesty the Queen in Right of Canada; 2017.
Available from: https://www.canada.ca/en/public-
health/services/publications/diseases-conditions/gonorrhea-alternate-
treatment.html
6. Health Protection and Promotion Act, R.S.O. 1990, Reg. 569, Reports, (2018).
Available from: https://www.ontario.ca/laws/regulation/900569
7. Ontario. Ministry of Health and Long-Term Care. Sexual Health and Sexually
Transmitted/ Blood-Borne Infections Prevention and Control Protocol, 2018.
Toronto, ON: Queen's Printer for Ontario; 2018. Available from:
9|Pagehttp://www.health.gov.on.ca/en/pro/programs/publichealth/oph_standard
s/protocolsguidelines.aspx
8. Ontario Agency for Health Protection and Promotion (Public Health Ontario),
Provincial Infectious Diseases Advisory Committee. Sexually Transmitted
Infections Case Management and Contact Tracing Best Practice
Recommendations. Toronto, ON: Queen’s Printer for Ontario; 2009. Available
from: https://www.publichealthontario.ca/-
/media/documents/S/2009/sti-case-management-contact-tracing.pdf
Case Definition Sources
Centers for Disease Control and Prevention. National Notifiable Disease Surveillance
System: Gonorrhea (Neisseria gonorrhoeae) - 2014 Case Definition [Internet]. Atlanta,
GA: U.S. Department of Health & Human Services; 2014 [cited February 14, 2018].
Available from: Gonorrhea (Neisseria gonorrhoeae) 2014 Case Definition | CDC
Ontario Agency for Health Protection and Promotion (Public Health Ontario). Ontario
Gonorrhea Testing and Treatment Guide, 2nd Edition. Toronto, ON: Queen's Printer
for Ontario; 2018. Available from:
https://www.publichealthontario.ca/en/diseases-and-conditions/infectious-
diseases/sexually-transmitted-infections/gonorrhea
Public Health Agency of Canada. Gonorrhoea. In: Case Definitions for Communicable
Diseases under National Surveillance. Canada Communicable Disease Report.
2009;35S2.
Public Health Agency of Canada. Canadian Guidelines on Sexually Transmitted
Infections [Internet]. Ottawa, ON: Her Majesty the Queen in Right of Canada; 2018
[cited May 15, 2018]. Available from: https://www.canada.ca/en/public-
health/services/infectious-diseases/sexual-health-sexually-transmitted-
infections/canadian-guidelines/sexually-transmitted-infections.html
10 | P a g eDocument History
Revision Date Document Section Description of Revisions
April 2022 Entire Document New template. Appendix A and B
merged. No material content changes.
April 2022 Epidemiology: Removed.
Occurrence section
April 2022 ICD Codes Removed.
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